Understanding delayed access to antenatal care: a qualitative study Rosalind Haddrill

5.2.2 Knowing

A large group of women in the study knew that they were pregnant at an early gestation however, for a variety of reasons, delayed accessing antenatal care. These women fell into two groups: i) those that wanted to avoid care and ii) those that intended to postpone their antenatal care until a future, more convenient, date. In some cases this was a passive avoidance or postponement, in others women actively chose to conceal their pregnancies or delay access, though few women concealed their pregnancies from everyone. The boundary between avoidance and postponement was sometimes indistinct: the number of women avoiding antenatal care was small (five), however for some of these women what started as avoidance became postponement, as their pregnancy progressed and more people became aware.

5.2.2.1 Avoidance

5.2.2.1.1 Fear and ambivalence

Delay in confirming the pregnancy

In some cases women expressed ambivalence about confirming their pregnancies, with some stating that they had been in denial about their situation. With all of these women there was the suggestion that this had contributed to a delay in accessing care, whether by avoidance or postponement.

I: “How did you find out you were pregnant?

I just thought cos I were putting on a lot of weight and I wasn’t feeling very well. So I just thought that I’d just do it myself.

I: So did you do a pregnancy test?

I didn’t, no, because I didn’t want to think about it.”

(#7, G1P0, age 18)

“I had an idea about two months before, but I did a pregnancy test and that didn’t work, it didn’t say negative or positive, just no result come up. I did two [pregnancy tests] and they weren’t positive.

I: They were both inconclusive?

Yes… So then I just put it to the back of my mind, and my mum mentioned it again in a little while and I did another pregnancy test and that worked.”

(#14, G1P0, on methadone)

“I think just in denial really. I don’t think I was – I didn’t really want to be pregnant at that time I don’t think. I was trying to lose weight and it was like selfish reasons really… in the back of my mind I always knew really but at the same time I didn’t want to say anything to anyone, I didn’t want to think about it” (#11, G3P2)

Fear of the ‘consequences’ of pregnancy

Women experienced a huge range of emotions when discovering they were pregnant. Fear and anxiety about a frequently unplanned pregnancy were common and influenced a woman’s ability to access care. Some women chose to avoid antenatal care, having no clear plans to access it. This process of avoidance lasted from weeks to months, though whether this was a passive or active process was sometimes unclear. The primary theme associated with avoidance was fear, with some women fearful of the social consequences of the pregnancy. One substance-misusing woman, whose other children had been removed and adopted, feared the response of professionals such as her GP and removal of the baby by social services. She avoided antenatal care until being admitted at 33 weeks gestation with a suspected Deep Vein Thrombosis.

“I was scared at first, because of what happened before [three previous children removed]. It was a bit of a shock, you know what I mean, when, when I sort of, like, really knew, the shock, I was scared.”
“Some doctors are nice, some are horrible. Just suppose they know you take drugs, treat you nasty, not very nice.

I: Do you feel like people are judging you?

Yeah.

I: Has that ever put you off going to see the doctors before?

Yeah… it does stop people from going to the doctors when they’re like that.”

(#25, G4P3, on methadone)

Some younger women were concerned they would be judged and labelled as irresponsible after becoming pregnant unexpectedly. For three young women, all teenagers, it was the reaction of their families that they were fearful of, combined with the worry of the stigma and the negative stereotypes that exist surrounding teenage pregnancy, that led to them to avoid accessing antenatal care. In some cases this led the woman to conceal her pregnancy for a significant length of time:

“Probably when I was seven months pregnant, it came out. I didn’t want to tell my mum. It was very bad [her mum’s reaction].”

(#5, G2P1, previous concealed pregnancy aged 17)
“I keep it a secret at first, from my Mum, then I told her. She’d go mad at first. And my Grandad, my Grandad and my Mum”

(#23, G1P0, age 17, learning difficulties)

One young woman put her delay in accessing care (she finally booked at 36 weeks gestation) down to a combination of this fear and having other things going on in her life:

“I knew you had to go for all the tests and things like that, but I just couldn’t go. Cos I was only 17, just thought I couldn’t tell anyone, thought people’d look at me like…I don’t know, just like I was, irresponsible, yeh”

“I didn’t want to think about it. So I thought I’d just put it to the back of my mind, cos I was at college and I am in my last year and had quite a bit to do, so I thought I’d just forget about it… It were finding the right time to tell her [mum], cos I were at college… I didn’t know how she’d take it.”

(#7, G1P0, age 18)

Ambivalence towards pregnancy and antenatal care

Another reason for some women avoiding antenatal care was the significant ambivalence they described feeling towards the pregnancy and towards antenatal care. Consequently, there was active avoidance of antenatal care despite early symptoms being apparent to the pregnant woman and sometimes friends and family, who tried to influence them. These women were often from the most vulnerable groups i.e. women with a history of substance misuse and learning difficulties:

“I didn’t go see no-one, because I went with A to his house, in Chesterfield.

I: Did you have an appointment to go?

Yeah, I missed them, just didn’t want to go… I was with my boyfriend and I couldn’t be bothered to go.

I: Right, so there’s nothing that we could have done, or anybody else could have done, that would have made you go and see the midwife sooner?

No (laughs).”

(#23, G1P0, age 17, learning difficulties)

5.2.2.1.2 Coping mechanisms

Antenatal self-care

Alongside the denial and concealment demonstrated by some of the women in the study as coping mechanisms, a process of antenatal self-care was evident amongst a few women who avoided and postponed their antenatal care. One young woman, though a primigravida, described an intuitive process of ‘do it yourself antenatal care’ as a personal coping strategy, and a substitute for conventional care. This included self-checks, for example observing the baby’s growth and movements, and was based on her theoretical knowledge of pregnancy from college and her experience from observing other family members.

“I did look on posters and things like that and my cousin had just recently had a baby as well so I was looking at how she was with her pregnancy, things like that, how she coped with it… Because I knew quite a bit anyway I kept referring to my books and just checking and thinking ‘oh yeh it’s alright’ so there was nothing bad. Bits I’d got from college and things like that, so obviously I was thinking I can feel this so I don’t think there’s anything wrong”.

(#7, G1P0, age 18 years)

This particular woman admitted that she had made an active decision to conceal her pregnancy, and had decided to that she wanted to be in control about when to disclose the pregnancy to her family.

“He [baby’s dad) did give me advice and things like that but I just thought well, I’ll do what I want to. He were going on at me all the time to tell my mum and everyone. I just said I’ll tell them when I want to tell them.”

(#7, G1P0, age 18)